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Migraine Essentials in Primary Care Migraine Essentials in Primary Care

Migraine Essentials in Primary Care - PowerPoint Presentation

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Migraine Essentials in Primary Care - PPT Presentation

Britt Schloemer APRN 2018 KY NAPNAP Annual Update Objectives Describe what a migraine is Present an update on acute migraine treatment recommendations Discuss treatment options for migraine prevention ID: 918785

day migraine headache max migraine day max headache dose years triptan children age migraines headaches hours aura symptoms naproxen

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Slide1

Migraine Essentials in Primary Care

Britt Schloemer, APRN

2018 KY NAPNAP Annual Update

Slide2

Objectives

Describe what a migraine is

Present an update on acute migraine treatment recommendations

Discuss treatment options for migraine prevention

Discuss treatment and management priorities when caring for a child with migraines

Present resources that can be utilized by both patients and PCPs when treating and managing migraines

Slide3

Migraine

What is a migraine?

Slide4

International Headache Society (IHS) Diagnostic Criteria

(Patients < 15 years of age)

Migraine without aura:

Migraine with aura:

At least 5 attacks

Duration 4-72 hours

At least

2

of the following:

Unilateral

Pulsating quality

Moderate to severe intensity

Exacerbation by activity

At least

one

of the following:

Nausea, vomiting, or both

Photophobia or

phonophobia

 

At least 2 attacks

At least

3

of the following:

At least one fully reversible aura symptoms indicating focal, cerebral, cortical or brainstem dysfunction

At least one aura symptoms developing gradually for 4 minutes or ≥ 2 symptoms in succession

No aura > 60 minutes

Headache begins before, simultaneously, or within 60 minutes of aura

 

Slide5

Migraine Statistics

(Alfonzo & Chen, 2015)

Listed among the top 5 youth health problems

3

rd

most common referral to the ED

The most common cause of headache (HA) in children

Incidence and prevalence increases with age:3 – 7 years: 2%

7 - 11 years: 7%

11 – 15 years: 20%

Prepubertal

males: females – 3:2

Adolescent females: postpubescent males – 3:1

Slide6

What do parents do?

Slide7

What do they think is happening?

Slide8

But, what if…

Lee, 2017

Slide9

Red flags could indicate:

Increase in intracranial pressure

Focal irritation

Stroke

Infection

Red flag may indicate an emergency:

Refer to ED

Head CT

Slide10

Rare migraine variants

Can act like strokes

Hemiplegic migraine

Basilar artery migraine

Opthalmoplegic

migraine

Alice in Wonderland Syndrome

Confusional migraineMay not be associated with headache

Cyclic vomiting

Abdominal migraine

Benign paroxysmal vertigo

Benign paroxysmal torticollis

Slide11

Slide12

Lets talk imaging

U.S. Headache Consortium Guidelines for

Neuroimaging

in Patients Presenting With Headaches

Imaging is recommended:

In patients with non-acute headache and unexplained findings on neurologic examination

In patients with neurologic symptoms (headache that is worsened with use of Valsalva’s maneuver, awakens the patient from sleep, is newly onset in an older person, or is progressively worsening), the evidence is insufficient to make specific recommendations

In patients with a normal neurological examination if they have atypical features to their headache

An MRI is preferred to a CT scan for the above situations,

unless it is contraindicated or emergent

neuroimaging is needed.

Slide13

Back to the tumor question…

0.0056% of children exhibiting a typical migraine or headache will have a tumor

56 children out of 100,000

(personal communication, Elizabeth Doll, MD, 2018)

Your examination and history taking skills are vital

Slide14

Acute/ Abortive Treatment

Do not overlook the simple treatments requiring no Rx

Hydration

Sleep

Decrease stimulation

Dim lights

Medications

Non-steroidal anti-inflammatories

Triptans

Steroids

Over the counter combination therapies

Slide15

Some Contraindications

1

. Last dose of a

triptan

within 2 hours 

2. More than 2 doses of a

triptan

within a 24 hour period 

3. Last dose of

triptan

within 24 hours prior DHE 

4. Last dose of NSAID within 6 hours 

5. Pregnancy 

6. Breastfeeding 

7. Angina 

8. Ischemic heart disease 

9. Perivascular disease 

10. HTN 

11. CAD 

12. Concurrent MAO inhibitors or serotonin agonists 

13. Concurrent potent 3A4 inhibitors 

14. Concurrent peripheral and central vasoconstrictors 

15. Hemiplegic or Basilar migraine 

16. Severe hepatic and renal disease

Slide16

NSAIDS

Naproxen  > Ibuprofen > Acetaminophen

Naproxen

Approved for pain in ages >12

5 mg/kg or 500 mg PO initially, then 250 mg PO q6-8hr or 

500 mg PO q12hr PRN; 

not to exceed 1250 mg/day  on day 1; subsequent daily doses should not exceed 1000 mg

NSAID precautions and contraindications

At least 6 hours between doses

GI caution

Bleeding caution

More efficacious if given with a

triptan

Slide17

NSAIDS

Naproxen  > Ibuprofen > Acetaminophen

Ibuprofen

10 mg/kg/dose every 6 hours

Not to exceed 600 mg/dose or 40 mg/kg/day

Approved for children > 6 months of age

NSAID precautions

Twice as efficacious as acetaminophen

Acetaminophen

15 mg/kg/dose max 1000mg every 4 hours

Max daily dose of 75 mg/kg or 4000 mg

Slide18

NSAIDS

Age

Recommendation if no contraindications

Initial

Dose at onset of HA

> 12 years

Naproxen

5 mg/kg;

MAX 500mg at onset

6 months – 12 years

Ibuprofen

10 mg/kg; max 600mg

<6 months

Acetaminophen

15 mg/kg; max 1000mg

Slide19

Triptans

Produce vasoconstriction

Best if used early

May repeat, x1, 2 hours after initial dose if migraine persists

Many contraindications, including, but not limited to:

Stoke

CV disease,

HTNPregnancyPay attention to ages

Slide20

Triptans

(

Patniyot

, 2015)

Triptan

Age

Dose

Almotriptan

(

Axert

)

> 12 years

6.25 or 12.5 mg

Eletriptan

(

Relpax

)

> 12 years

40 mg

Rizatriptan

(

Maxalt

)

> 6 years

5 mg (<40 kg) to 10 mg

(>40kg)

Sumatriptan

(

Imitrex

)

> 12 years

> 18 years

*5 to 20 mg orally or 6 mg subcutaneously

5, 10, or 20 mg

intranasally

Zolmitriptan

(

Zomig

)

> 12 years

2.5 to 5 mg or 5 mg nasal spray

For young people aged 12–17 years

consider

a nasal

triptan

in preference to an oral

triptan

.

*lower doses were just as effective as higher doses with pain relief, but not associated symptoms

Slide21

Triptans

(

Patniyot

, 2015)

Recommendation: At onset of headache, administer Naproxen

AND

Triptan

For older children, intranasal triptan

is preferred over oral

Always consider indications and contraindications of medications

Slide22

Other Treatments

(Alfonzo & Chen, 2015) & (National Guideline Clearinghouse, 2012)

Sumatriptan

/Naproxen oral tablets (

Treximet

) 10/60mg up to 85/500mg; MAX x1 85/500mg tab/day

> 12 years of age

Nausea and vomiting: Ondansetron (Zofran) 0.1 mg/kg; MAX 8mg every 8 hours PRN

Dopamine Receptor Antagonists:

Promethazine (

Phernergan

): 0.25—1 mg/kg/dose; MAX 25 mg/dose

Metoclopramide: 0.1

0.2 mg/kg/dose; MAX 10mg

Consider diphenhydramine (

benadryl

)

DO NOT GIVE OPIOIDS

No research supports use of steroids

Abortive medications should not be used more than 2-3x/week or 10x/month

Mind and Body

Slide23

Preventing Migraines

Find the trigger

(Lee, 2017):

Slide24

When to prevent…

Consider:

Quality of life (QOL)

Degree of disability

HA characteristics: frequency, severity, duration

Generally,

1. If the patient has two (2) or more headaches per week that are associated with disability or 

2. > 3 incapacitating headaches per month or 

3. If the headache is predictable (ex. premenstrual migraine)

Prophylaxis takes up to 4-6 months to reduce HA frequency

Slide25

Preventative treatments

Antidepressants

Antihypertensives

Antiepileptics

Antihistamines

Other

Slide26

Antidepressants & Antihypertensives

(Hickman, Lewis, Little,

Rastogi

, &

Yonker

, 2015)

Antidepressants

Tricyclic Antidepressants (TCAs)Amitriptyline 0.25- 1 mg/kg/day; dose at bedtime; start low and increase to max of 75 mg/dayNortriptyline similar dosing to above; not as sedating

SSRIs more beneficial in adults than children

Antihypertensives

Beta Blockers: Propranolol 0.5-1 mg/kg/day divided BID (Initial MAX 80 mg/day) or Atenolol 0.5-1 mg/kg/day divided BID (Initial MAX 50 mg/day)

Calcium Channel Blockers: Verapamil 2-3 mg/kg/day divided BID (Initial MAX 240 mg/day)

BLACK BOX WARNING

Slide27

Antiepileptics

Antieplieptics

Topiramate

approved in children >12 for migraine; 2-3 mg/kg/day; MAX 200mg/day

CAUTION in girls of child bearing age

Kidney stones, word finding difficultiesIncrease dose slowly

Valproic

Acid

used in adults for migraine prevention; 10-20 mg/kg/day; MAX 1000 mg

CAUTION in girls of child bearing age

Thrombocytopenia

Weight gain!

BLACK BOX WARNING

Slide28

Antihistamines

Cyproheptadine

:

Used since the 1970’s in children to prevent headaches

Usually for younger children

0.2-0.4 mg/kg/day dosed at night

SEDATION

Appetite stimulant

Slide29

Other Treatments

Botulinum toxin

Fluid 

Drink at least 6 cups (1.5L) of water daily 

Remover or reduce caffeine from the diet

 

Sleep 

Maintain a regular sleep pattern every day 

Diet and exercise 

Eat 3 meals a day, do NOT skip meals 

Eat a protein source for breakfast 

Maintain a healthy body weight 

Exercise for 30 minutes daily

 

Mind and body 

Accupuncture

Biobehavior

techniques are beneficial 

Relaxation training 

Biofeedback 

Cognitive behavior therapy 

Stress management 

Supplements 

Magnesium Oxide 9 mg/kg/day BID (MAX 600 mg/day) 

Coenzyme Q10 1-3 mg/kg/day daily (MAX 150 mg/day) 

Vitamin B2 200-400 mg/day daily

Slide30

When to refer

Abnormal brain imaging

Migraines with unusual neurological symptoms

Chronic migraines

15 or more headaches a month for three months or longer, often as a result of medication overuse

Intractable migraines

Migraines not helped by medications

Any headache outside the clinical criteria for migraine or tension-type headache There are more than 200 different types of headache disorders in the International Classification of Headache Disorders. Although migraines and tension-type headaches are most common, there are a myriad of other headache disorders.

Slide31

But…

Do not be afraid to start approved or recommended treatments, both acute and preventative

It may take months for preventative medications to take effect!

Slide32

Lee, K. H. (2017). Recent updates on treatment for pediatric migraine.

J Korean Med Association

. Feb;60(2):118-125.

https://doi.org/10.5124/jkma.2017.60.2.118

National Guideline Clearinghouse (NGC). Guideline summary: Headaches: diagnosis and management of headaches in young people and adults. In: National Guideline Clearinghouse (NGC) [Web site]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2012 Sep 01. [cited 2018 Jan 20]. Available: https://

www.guideline.gov